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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A nurse in an outpatient obstetric clinic is evaluating the electronic fetal monitoring tracing of a nonstress test (NST) for a client at 38 weeks of gestation. Over a 20-minute monitoring period, the baseline fetal heart rate is 135 beats per minute. The nurse observes two fetal heart rate accelerations that peak at 155 beats per minute and last for 15 seconds each. There are no decelerations present on the tracing. Which of the following actions should the nurse take based on these findings?

  1. Document the findings as a reactive nonstress test.Answer
  2. B
    Prepare the client for an immediate contraction stress test.
  3. C
    Notify the healthcare provider of fetal baseline tachycardia.
  4. D
    Reposition the client to the left lateral side and administer oxygen.

Answer

The correct action is to document the findings as a reactive nonstress test because the criteria of two accelerations (at least 15 beats per minute above baseline lasting 15 seconds) within 20 minutes have been met.
The correct answer is to document the findings as a reactive nonstress test. For a fetus at 32 weeks of gestation or older, a reactive (normal) NST is defined by a baseline heart rate between 110 and 160 beats per minute, accompanied by at least two accelerations of 15 beats per minute or more above the baseline, lasting at least 15 seconds each, within a 20-minute window. Since this client's tracing perfectly matches these criteria and lacks decelerations, it is reassuring and requires only standard documentation.

Step-by-Step Solution

1
Identify the baseline fetal heart rate from the clinical data.
The baseline fetal heart rate is 135 beats per minute.
Establishing the baseline is necessary to determine if the heart rate is within the normal range of 110 to 160 beats per minute.
2
Analyze the characteristics of the observed accelerations.
There are two accelerations peaking at 155 beats per minute (which is 20 beats above the baseline) and lasting 15 seconds each.
To determine reactivity, accelerations must be quantified by their height above the baseline and their duration.
3
Compare the findings against the criteria for a reactive nonstress test (NST) in a term fetus.
The findings meet the "15 by 15" rule (at least two accelerations of at least 15 beats per minute lasting at least 15 seconds within a 20-minute period).
Meeting these standard criteria confirms that the fetus is well-oxygenated and the central nervous system is intact.
4
Determine the appropriate nursing intervention for a normal assessment.
The nurse should document the reassuring findings.
Because the tracing is normal and reactive, emergency interventions and further diagnostic testing are unnecessary.

Key Concept

Interpretation of Antepartum Nonstress Test (NST) Reactivity Criteria
Estimated Time:1m 0s
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Topics

Ante/Intra/Postpartum and Newborn Care

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